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CyberKnife Radiosurgery in the Treatment of Early and
Advanced (Oligo-Metastases) Breast Cancer
Sandra Vermeulen, MDCo- Director,
Seattle CyberKnife CenterSeattle, Wa
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Breast Conservation Therapy Treatment Objectives
• Acceptable cosmesis
• Local control of disease
• Minimal treatment complications
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In 2000 the National Cancer Data Base reported that only 50% of eligible
candidates received conservative surgery followed by radiation therapy
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Prospective Randomized TrialsBCS + RT vs MRM
Trial LR % Survival % F/U
BCT vs MRM BCT vs MRM Years
NSABP 14 v 10 47 v 46 20
Milan 9 v 2 59 v 59 20
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External Beam Coverage of the Breast and Inclusion of
Normal Tissues
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Advantages of Partial Breast Irradiation over Whole Breast
Treatment
• Decreased time and inconvenience
• Decreased acute and chronic toxicity
• Improved radiation therapy underutilization
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Regional Failures within the Breast
Trial CS Alone CS + RT
NSABP 2.7 17/636 3.8 24/629
Ontario 3.5 15/421 0.9 4/416
Milan 2.8 8/280 0.6 2/299
Finland 5.5 4/72 5.0 4/80
Sweden 1.5 3/194 0.5 1/187
Range (%) 1.5-5.5 0.5-5.0
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Techniques for Partial Breast Irradiation
• 3-D conformal external beam radiotherapy
• Multi-catheter brachytherapy• Balloon catheter brachytherapy• Intra-operative Radiotherapy
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IORTVeronesi et al: A preliminary report of IORT
in limited stage breast cancers that are conservatively treated. Eur J Cancer. 2001
Nov;37(17):2178-83
Mobile linear accelerator
3-9 Mev eb
10-21 Gy in 103 patient
No complications
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NSABP Protocol B-39RTOG Protocol 0413
A randomized Phase III Study of Conventional Whole Breast Irradiation vs Partial Breast
Irradiation for Women with Stage 0, I, II Breast Cancer
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NSABP Dose Prescription
• 3D Conformal External Beam Radiotherapy38.00 Gy total dose at 3.85 Gy per fraction delivered twice
daily in 10 fractions over 5 treatment days
• Multi-Catheter and Balloon catheter Brachytherapy34 Gy total dose at 3.4 Gy per fraction delivered twice
daily in 10 fractions over 5 treatment days
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NSABP Target Volume for 3D-CRT
The CTV is defined by expanding the excision cavity volume by 15 mm.
The PTV includes a 10 mm expansion of the CTV to compensate for patient motionpatient motion and variability of
treatment set-up
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CyberKnife
• Approved by the FDA since 2001
• Nearly 30,000 patients treated worldwide
• More than 200 peer review papers have been published
• More than 80 hospitals and medical centers provide CyberKnife technology
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How is the technology different?
• Advanced interactive robotics
• Real-time imaging
• Dynamic automated motion tracking
• Flexible and accurate linac multiple-beam radiation delivery
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Methods for tracking motion
• Skull and spine tracking: bony landmarks are tracked
• Fiducial tracking: radio-opaque marker are placed near soft tissue targets and tracked
• Respiratory tracking (Synchrony): with respiration, LED’s on the exterior of the patient are correlated with the movement of the target/tumor and fiducials
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Respiratory Tracking
Beam Off
Beam OffBeam On
Beam On
Treatment Field
1.1. 2.2.
3.3. 4.4.
Gating SynchronyTM
Treatment beam is turned on and off as tumor enters and exits a static treatment field
Dynamic treatment field follows the tumor while the treatment beam is turned on
= Over-treated healthy tissue
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Accuracy• When used properly, Synchrony™ provides a
degree of accuracy of better than 1.5mm– Allows reduced planning margins for lesions that
move with respiration
• Gating and breath holding require margins of 5-10mm to compensate for setup and targeting uncertainty
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Indications for Cyberknife
• Intracranial lesions: single fraction, or fractionated• Head and neck:
– Nasopharynx & base of skull, primary or recurrent– Other sites, as boost following conventional RT, or recurrent
• Spine: where surgery indicated but not feasible, and conventional RT less effective or not possible
• Lung: where surgery indicated but not feasible• Liver: where surgery indicated but not feasible• Pancreas: unresectable but localized tumors• Kidney: where surgery indicated but not feasible• Previously irradiated tumors: retreatment w/ conventional
RT not possible, for severe symptoms, Karnofsky > 40
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A phase II Study of CyberKnife Radiosurgery delivered to the
Partial Breast for Women with Stage 0, I, II Breast Cancer
Seattle CyberKnife
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Primary and Secondary Aims of Study
This study will evaluate the technical feasibility of PBI with the
CyberKnife as well as evaluate QOL issues that relate to treatment side-
effects, cosmetic outcomes and patient convenience
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Patient Eligibility
• Stage 0, I, II non-lobular breast cancer• Cancer must be ≤ 3 cm• Surgical treatment must be a lumpectomy• Margins must be > 2mm for both DCIS and
invasive disease• Negative sentinel Lymph node(s) or an axillary
dissection • Lumpectomy cavity must be clearly delineated
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Justification of Radiosurgical Dose
By applying the linear-quadratic cell survival model with an alpha-beta
ratio of 4, a dose of 30 Gy given in 5 stages of 6 Gy between 5 to 10 days
is radiobiologically equivalent in tumor control and late breast tissue complications as the whole breast
doses used by NSABP
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Partial Breast Planning for CyberKnife
• The CTV is the excision rim plus a 10 mm margin in all directions
• The PTV is defined as the CTV plus a 5mm margin• The dose is will be delivered to the 70 - 85%
isodose prescription line
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Cyberknife Radiosurgery for Early Breast Cancer: a pilot investigation
to determine the feasibility of Synchrony imaging and fiducial
identification for motion tracking
Seattle Cyberknife
Fresno Community Regional Medical Center
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Protocol Objectives
• To determine if there is sufficient geometric stability of gold markers in the breast for Synchrony motion tracking
• To determine the optimal patient treatment position for Synchrony motion tracking
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Seattle CyberKnife Summary• Greater than 140 sites treated including
primary tumors of the lung, brain, prostate and
metastases to the lung, liver, brain and bone
• June 2007 to begin a breast pilot to determine the feasibility of Synchrony motion tracking
• January 2008 planned open enrollment for a multi-institutional PBI protocol using Cyberknife